Erik Kulstad

A Comparison of the Effects of Etomidate and Midazolam on Hospital Length of Stay in Patients With Suspected Sepsis: A Prospective, Randomized Study

STUDY OBJECTIVE Etomidate, a widely used induction agent for rapid sequence intubation in the emergency department (ED), causes measurable adrenal suppression after a single bolus dose. The clinical significance of this adrenal suppression in patients with sepsis remains controversial. We seek to determine the difference in hospital length of stay between patients with suspected sepsis who receive either etomidate or midazolam during intubation in our ED. METHODS We performed a prospective, double-blind, randomized study of patients with suspected sepsis who were intubated in our ED during an 18-month period. Eligible patients who were critically ill and were suspected of having sepsis were randomized to receive either etomidate or midazolam before intubation. RESULTS A total of 122 patients were enrolled; 59 received midazolam and 63 received etomidate. Two patients in the etomidate group were lost to follow-up. Patient baseline characteristics were similar between groups. There were no significant differences in median hospital length of stay (9.5 versus 7.3 days), ICU length of stay (4.2 versus 3.1 days), or ventilator days (2.8 versus 2.1) between patients who received midazolam and those who received etomidate, respectively. Inhospital mortality was 21 of 59 (36%; 95% confidence interval 24% to 49%) for patients who received midazolam and 26 of 61 (43%; 95% confidence interval 30% to 56%) for patients who received etomidate. For patients who survived to hospital discharge, the median length of stay was 11.3 days in the midazolam group versus 11.8 days in the etomidate group; for patients who died, the median length of stay was 2.9 days in the midazolam group versus 3.3 days in the etomidate group. CONCLUSION Patients with suspected sepsis and who received a single bolus dose of etomidate for rapid sequence intubation showed no significant increase in hospital length of stay compared with patients who received a single bolus dose of midazolam.

A Prospective Observational Study of the Effect of Etomidate on Septic Patient Mortality and Length of Stay

OBJECTIVES Etomidate is known to cause adrenal suppression after single-bolus administration. Some studies suggest that when etomidate is used as an induction agent for intubation of septic patients in the emergency department (ED), this adrenal suppression leads to increased mortality, vasopressor requirements, and length of hospital stay. The authors sought to determine differences in the in-hospital mortality and hospital length of stay (LOS) between septic patients given etomidate and patients given alternative or no induction agents for rapid-sequence intubation in our ED. METHODS This was a nonrandomized, prospective observational study of all patients meeting sepsis criteria who were intubated in an ED over a 9-month period. Times of patient presentation, intubation, admission, discharge, and/or death were recorded, as well as the intubation agent used, if any, and corticosteroid use. The authors also recorded relevant laboratory and demographic variables to determine severity of illness using the Mortality in Emergency Department Sepsis (MEDS) score. Mortality and survivor LOS between the patients given etomidate and those given alternative or no induction agents were compared. RESULTS A total of 106 patients with sepsis were intubated over the study period. Of these, 74 patients received etomidate, while 32 patients received ketamine, benzodiazepines, propofol, or no induction agents. Age in years (median = 78; interquartile range [IQR] = 67 to 83), gender (45% male), MEDS score (median = 13; IQR = 10 to 15), and receipt of supplemental corticosteroids (56%) were statistically similar between the two groups. In-hospital mortality of patients given etomidate (38%; 95% confidence interval [CI] = 28% to 49%) was similar to those receiving alternatives (44%; 95% CI = 28% to 61%). Surviving patients had a median hospital LOS after receiving etomidate of 10 days compared to those receiving alternatives (7.5 days; p = 0.08). CONCLUSIONS No statistically significant increase in hospital LOS or mortality in patients given etomidate for rapid-sequence intubation was found. Suggestions that the use of etomidate for intubation in the ED be abandoned are not supported by these data.

Morbidity related to emergency endotracheal intubation—A substudy of the KETAmine SEDation trial

OBJECTIVES To evaluate the association between emergency tracheal intubation difficulty and the occurrence of immediate complications and mortality, when standardised airway management is performed by emergency physicians. METHODS The present study was a substudy of the KETAmine SEDation (KETASED) trial, which compared morbidity and mortality after randomisation to one of two techniques for rapid sequence intubation in an emergency setting. Intubation difficulty was measured using the intubation difficulty scale (IDS) score. Complications recognised within 5 min of endotracheal intubation were recorded. We used multivariate logistic regression analysis to determine the factors associated with the occurrence of complications. Finally, a Cox proportional hazards regression model was used to examine the association of difficult intubation with survival until 28 days. RESULTS A total of 650 patients were included, with mean age of 55 ± 19 years. Difficult intubation (IDS >5) was recorded in 73 (11%) patients and a total of 248 complications occurred in 192 patients (30%). Patients with at least one complication had a significantly higher median IDS score than those without any complications. The occurrence of a complication was independently associated with intubation difficulty (odds ratio 5.9; 95% confidence interval (CI) [3.5;10.1], p < 0.0001) after adjustment on other significant factors. There was a positive linear relationship between IDS score and complication rate (R(2) = 0.83; p < 0.001). The Cox model for 28-day mortality indicated that difficult intubation (hazard ratio 1.59; 95%CI [1.04;2.42], p = 0.03) was a significant independent predictor of death. CONCLUSION Difficult intubation, measured by the IDS score, is associated with increased morbidity and mortality in patients managed under emergent conditions.

Emergency Department Crowding is Associated with Reduced Satisfaction Scores in Patients Discharged from the Emergency Department

Introduction Emergency department (ED) crowding has been shown to negatively impact patient outcomes. Few studies have addressed the effect of ED crowding on patient satisfaction. Our objective was to evaluate the impact of ED crowding on patient satisfaction in patients discharged from the ED. Methods: We measured patient satisfaction using Press-Ganey surveys returned by patients that visited our ED between August 1, 2007 and March 31, 2008. We recorded all mean satisfaction scores and obtained mean ED occupancy rate, mean emergency department work index (EDWIN) score and hospital diversion status over each 8-hour shift from data archived in our electronic tracking board. Univariate and multivariate logistic regression analysis was calculated to determine the effect of ED crowding and hospital diversion status on the odds of achieving a mean satisfaction score ≥ 85, which was the patient satisfaction goal set forth by our ED administration. Results: A total of 1591 surveys were returned over the study period. Mean satisfaction score was 77.6 (standard deviation [SD] ±16) and mean occupancy rate was 1.23 (SD ± 0.31). The likelihood of failure to meet patient satisfaction goals was associated with an increase in average ED occupancy rate (odds ratio [OR] 0.32, 95% confidence interval [CI] 0.17 to 0.59, P < 0.001) and an increase in EDWIN score (OR 0.05, 95% CI 0.004 to 0.55, P = 0.015). Hospital diversion resulted in lower mean satisfaction scores, but this was not statistically significant (OR 0.62, 95% CI 0.36 to 1.05). In multivariable analysis controlling for hospital diversion status and time of shift, ED occupancy rate remained a significant predictor of failure to meet patient satisfaction goals (OR 0.34, 95% CI 0.18 to 0.66, P = 0.001). Conclusion: Increased crowding, as measured by ED occupancy rate and EDWIN score, was significantly associated with reduced patient satisfaction. Although causative attribution was limited, our study suggested yet another negative impact resulting from ED crowding.

ED crowding is associated with an increased time to pneumonia treatment

OBJECTIVE We measured the correlation between emergency department (ED) occupancy rate and time to antibiotic administration for patients with pneumonia treated in a community hospital setting. METHODS We reviewed quality improvement data on patients treated for pneumonia in our ED and admitted over a 5-month period. The outcomes were timeliness of antibiotic therapy (within 4 hours of arrival) and overall time to antibiotic administration. Emergency department crowding was measured as the ED occupancy rate. We calculated (1) the Spearman correlation between occupancy rate at time of patient presentation and the time to antibiotic administration, (2) the odds ratio of receiving antibiotics within 4 hours with increasing ED occupancy, and (3) the ability of the occupancy rate to predict failure of achieving the 4-hour goal with the receiver operating characteristic curve. RESULTS A total of 334 patients were treated over the study period, of which 262 had complete data available. Occupancy rate ranged from 20% to 245%, and median was 137%. Eighty-one percent received antibiotics within 4 hours; the median time was 150 minutes. Time to antibiotics showed a positive correlation with occupancy rate (Spearman ρ = 0.17, P = .008). An increasing ED occupancy rate was associated with decreased odds of receiving antibiotics within 4 hours (odds ratio, 0.31; 95% confidence interval, 0.13-0.75). Receiver operating characteristic curve area was 0.62 (95% confidence interval, 0.54-0.70; P = .009). CONCLUSION Emergency department occupancy rate was associated with increased time to antibiotic treatment for patients admitted with pneumonia. Occupancy rate had fair success in predicting failure of treatment within 4 hours.

Measures of stress and learning seem to be equally affected among all roles in a simulation scenario.

Introduction: Simulation scenarios provide a realistic, stressful environment in which participants can gain new clinical knowledge. It is unclear whether the role a participant plays in a scenario affects these goals. We measured heart rate, self-perceived stress and learning value, and objective written test results of participants in two simulation scenarios. Our hypothesis was that measurements of participants’ stress and learning would be similar among all team members in our simulated scenarios. Methods: Residents and medical students were prospectively randomized to take part in two difficult airway scenarios in the roles of team leader, procedure chief, or team member. Heart rate was recorded using pulse oximetry preprocedure and at the critical airway intervention. After debriefing, participants completed a data collection form that included visual analog scales for perceived stress and learning and objective questions related to scenario teaching points. Results: We obtained 53 measurements during a single day. Heart rates increased during the airway intervention (median 4 beats per minute, P = 0.04). Self-reported learning values increased with self-reported stress level (rs = 0.373, P = 0.01); however, no correlation was found between a participant’s role in the scenario and heart rate, test score, stress level, or perceived learning benefit. Conclusions: In our limited scenarios, measurements of stress and learning did not differ by role. Our results support the concept that all participants may benefit from simulation scenarios.

Comparison of severity of illness scoring systems in the prediction of hospital mortality in severe sepsis and septic shock

Background: New scoring systems, including the Rapid Emergency Medicine Score (REMS), the Mortality in Emergency Department Sepsis (MEDS) score, and the confusion, urea nitrogen, respiratory rate, blood pressure, 65 years and older (CURB-65) score, have been developed for emergency department (ED) use in various patient populations. Increasing use of early goal directed therapy (EGDT) for the emergent treatment of sepsis introduces a growing population of patients in which the accuracy of these scoring systems has not been widely examined. Objectives: To evaluate the ability of the REMS, MEDS score, and CURB-65 score to predict mortality in septic patients treated with modified EGDT. Materials and Methods: Secondary analysis of data from prospectively identified patients treated with modified EGDT in a large tertiary care suburban community hospital with over 85,000 ED visits annually and 700 inpatient beds, from May 2007 through May 2008. We included all patients with severe sepsis or septic shock, who were treated with our modified EGDT protocol. Our major outcome was in-hospital mortality. The performance of the scores was compared by area under the ROC curves (AUCs). Results: A total of 216 patients with severe sepsis or septic shock were treated with modified EGDT during the study period. Overall mortality was 32.9%. Calculated AUCs were 0.74 [95% confidence interval (CI): 0.67–0.81] for the MEDS score, 0.62 (95% CI: 0.54–0.69) for the REMS, and 0.59 (95% CI: 0.51–0.67) for the CURB-65 score. Conclusion: We found that all three ED-based systems for scoring severity of illness had low to moderate predictive capability. The MEDS score demonstrated the largest AUC of the studied scoring systems for the outcome of mortality, although the CIs on point estimates of the AUC of the REMS and CURB-65 scores all overlap.

Evaluation of the revised trauma and injury severity scores in elderly trauma patients

Background: Severity-of-illness scoring systems have primarily been developed for, and validated in, younger trauma patients. Aims: We sought to determine the accuracy of the injury severity score (ISS) and the revised trauma score (RTS) in predicting mortality and hospital length of stay (LOS) in trauma patients over the age of 65 treated in our emergency department (ED). Materials and Methods: Using the Illinois Trauma Registry, we identified all patients 65 years and older treated in our level I trauma facility from January 2004 to November 2007. The primary outcome was death; the secondary outcome was overall hospital length of stay (LOS). We measured associations between scores and outcomes with binary logistic and linear regression. Results: A total of 347 patients, 65 years of age and older were treated in our hospital during the study period. Median age was 76 years (IQR 69-82), with median ISS 13 (IQR 8-17), and median RTS 7.8 (IQR 7.1-7.8). Overall mortality was 24%. A higher value for ISS showed a positive correlation with likelihood of death, which although statistically significant, was numerically small (OR=1.10, 95% CI 1.06 to 1.13, P<0.001). An elevated RTS had an inverse correlation to likelihood of death that was also statistically significant (OR=0.48, 95% CI 0.39 to 0.58, P<0.001). Total hospital LOS increased with increasing ISS, with statistical significance decreasing at the highest levels of ISS, but an increase in RTS not confirming the predicted decrease in total hospital LOS consistently across all ranges of RTS. Conclusions: The ISS and the RTS were better predictors of mortality than hypothesized, but had limited correlation with hospital LOS in elderly trauma patients. Although there may be some utility in these scores when applied to the elderly population, caution is warranted if attempting to predict the prognosis of patients.

Absolute and relative changes (delta) in troponin I for early diagnosis of myocardial infarction: Results of a prospective multicenter trial

OBJECTIVES We investigated absolute and relative cardiac troponin I (TnI) delta changes, optimal sampling protocols, and decision thresholds for early diagnosis of myocardial infarction (MI). Serial cardiac biomarker values demonstrating a rise and/or fall define MI diagnosis; however the magnitude of change, timing, and diagnostic accuracy of absolute versus relative (percentage) deltas remains unsettled. METHODS We prospectively measured TnI (AccuTnI+3™, Beckman Coulter) at serial time intervals in 1929 subjects with chest pain or equivalent symptoms of acute coronary syndrome at 14 medical centers. Diagnosis was adjudicated by an independent central committee. RESULTS Elevated TnI above a threshold of 0.03ng/mL demonstrated significant diagnostic efficacy (AUC 0.96). For patients with TnI<0.03ng/mL and symptom onset≥8h, 99.1% (NPV) were diagnosed with conditions other than MI. Absolute delta performed significantly better than relative delta at 1-3h (AUC 0.84 vs 0.69), 3-6h (0.85 vs 0.73), and 6-9h (0.91 vs 0.79). Current recommendations propose ≥20% delta within 3-6h; however, results were optimized using an absolute delta of 0.01 or 0.02ng/mL. Sensitivity results for absolute delta at 1-3h and 3-6h (75.8%, 78.3%) were superior to relative delta (48.0%, 61.3%). NPV (rule out) was 99.6% when baseline TnI<0.03ng/mL and absolute delta TnI<0.01ng/mL. CONCLUSIONS Absolute delta performed significantly better than relative delta at all time intervals. Baseline TnI and absolute delta may be used in conjunction to estimate probability of MI. Consensus recommendations are supported for sampling on admission and 3h later, repeated at 6h in patients when clinical suspicion remains high.

Diagnostic performance of cardiac Troponin I for early rule-in and rule-out of acute myocardial infarction: Results of a prospective multicenter trial☆

OBJECTIVES To compare emergency department TnI serial sampling intervals, determine optimal diagnostic thresholds, and report representative diagnostic performance characteristics for early rule-in and rule-out of MI. METHODS We prospectively measured TnI (AccuTnI+3™, Beckman Coulter) at serial time intervals in 1929 subjects with chest pain or equivalent ischemic symptoms suggestive of acute coronary syndromes at 14 medical centers. Diagnosis was adjudicated by an independent central committee. RESULTS TnI ≥0.03ng/mL provided 96.0% sensitivity and 89.4% specificity at 1-3h after admission, and 94.9% sensitivity and 86.7% specificity at 3-6h. NPV (rule-out, non-MI) was 99.5% at 1-3h, and 99.0% at 3-6h when TnI is <0.03ng/mL. NPV was 99.1% when TnI is <0.03ng/mL and time of symptom onset is ≥8h. Approximately 50-58% (PPV) of patients with TnI ≥0.03ng/mL were diagnosed with MI, depending upon time from onset or admission; PPVs emphasize the importance of serial samples and delta TnI (rising or falling pattern) when low cutoffs are used. Nevertheless, even a single elevated TnI value increased the risk of MI. As TnI values rose, the probability of MI increased. Values ≥0.20ng/mL were associated with nearly 90% probability of MI. CONCLUSIONS We report a large multicenter prospective adjudicated trial assessing troponin for early rule-in and rule-out using the Universal Definition of MI and conducted in primary care hospital-associated emergency departments. Our study demonstrates high diagnostic accuracy at early observation times, and reinforces consensus recommendations for sampling on admission and 3h later, repeated at 6h when clinical suspicion remains high.